Transitions of Care Patient Navigator

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Mass General Brigham Community Physicians, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Job Summary As an integral member of the Population Health Management Operations team, the Transitions of Care (TOC) Coordinator will support Medicare Shared Savings Program (MSSP) and Medicaid ACO patients as they transition from an inpatient hospital stay to their homes. In this role, the Coordinator will work closely with a team of nurses and a pharmacist to facilitate care coordination, ensure timely access to discharge information, and support patients in navigating follow-up needs.

Key Responsibilities:

• Ensure patient discharge summaries are obtained, documented, and available in Epic by coordinating with hospitals, healthcare providers, and other relevant parties.
• Run daily reports to identify discharges, manage enrollment or closure of episodes, and confirm discharge documentation.
• Monitor and triage patient text message responses, escalating concerns to the appropriate team member.
• Coordinate and track follow-up appointments and collaborate with practice staff to resolve scheduling barriers.
• Make outreach calls to patients for follow-up care, appointment reminders, and to address care coordination needs.
• Assist patients with resource needs in the patient's community such as identifying transportation resources to ensure attendance at transitions of care appointments.
• Participate in team discussions to identify patient needs, escalate concerns, and ensure timely interventions.
• Identify opportunities to streamline workflows, enhance communication, and improve overall care coordination efficiency.
• Maintain a balance of operational efficiency while upholding the highest quality of patient care.

Qualifications Qualifications:

Bachelor's Degree Healthcare Management or other related field of study required. Relevant experience can be accepted in lieu of degree. 1+ years case management, patient facing, medical office or related field, preferably in a clinical setting required. Epic experience preferred.

Additional Knowledge, Skills and Abilities:

• Strong knowledge of healthcare resources, community services, and patient advocacy.
• Excellent communication and interpersonal skills.
• Ability to collaborate effectively with healthcare professionals across multiple disciplines and experiences.
• Strong organizational and time management skills.
• Familiarity with electronic health records and case management software.

Additional Job Details (if applicable)

Schedule and Work Model:

Full-Time, Monday through Friday, standard business hours.

Hybrid work model:

Mostly remote with in-office requirement at Assembly Row in Somerville, MA approximately once per month. On remote workdays, employees must use a stable, secure, and compliant workstation in a quiet environment. Teams Video is required and must be accessed using MGB-provided equipment. Remote Type Hybrid Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $22.22

• $31.

71/Hourly Grade 5 At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement:

6010 Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857

• 282-7642.

Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline. Combat disease. Hold a hand. Help people. Impact the world. Mass General Brigham is a passionate, welcoming community where minds meet caring hearts. Come be a part of the world's most powerful force in medicine, where every role is important in changing lives. Are you ready? Our history includes New England hospitals founded over 200 years ago, some of the first and most prestigious hospitals in the world. Built on the legacy of two leading academic medical centers, we're more than a system—we're leaders in the practice of medicine. Mass General Brigham is committed to serving the community. We are dedicated to enhancing patient care, teaching and research, and taking a leadership role as an integrated health care system. We recognize that increasing value and continuously improving quality are essential to maintaining excellence.